Satisfaction?

Introduction

I am in the beginnings of reading applications from those who are seeking admission to the two medical schools on which I serve on admissions committees. If there are common themes in the personal statements, they center around a strong desire to make a difference in the lives of future patients; to interact and reach those who need care. In short, most people who desire to enter medicine are interested in being of service to other humans.

In stark contrast, as I interact with members of my medical societies, I hear countless stories of increased disappointment in medical practice. From despair at being a “cog in the wheel of profit-making” to “I just can’t keep up with the paperwork”, my colleagues are far less satisfied with their daily work and are increasingly looking for ways to exit medicine especially those who work in primary care (read on the front-lines).

Changes

Most physicians in today’s practice are employees of health systems\groups. The days of a practice such as that which my father and uncle enjoyed (two-physician Internal Medicine Practice and affiliation with one hospital), are gone. A couple of my “radical” colleagues have renounced the world of third-party payers and moved into their clinics where autonomy is of greatest importance. These autonomous colleagues have joined the ranks of concierge medicine where their patient cohorts pay a flat fee for unlimited access (not bad unless you have too many patients) or direct payment, often scaled. It is no accident that my colleagues who have the most autonomy over their practices are the most satisfied even if their income is less.

Additionally, when one begins practice, one has to have an income (loans have to be repaid and debt is certainly a burden) and one has to have some means of gaining experience with the skills learned in residency/fellowship. While the learning curve is steep; my younger colleagues understand and appreciate this but the constant erosion of personal time, income and increasing administrative tasks (scrutiny from those outside of medicine) have left many with a sense of hopelessness from lack of control.

A wonderful colleague in Family Medicine related that her administrative supervisor admonished her for not seeing enough patients even though she brought in the most revenue of her group and is probably the most efficient member of the group. She said that she spent hours developing patient aids and methods of getting patients seen, problems addressed and appropriate follow-up only to be told that she has to increase the number of people seen by 25% or face a cut in salary; certainly demoralizing.

Dissatisfaction?

I always remember my favorite residency professor telling me that “surgeons are not made, they are forged”. My forging was a relentless pursuit of honing my surgical technique along with the mental agility to assess my patients and take necessary action. I thrived in the environment of the constant challenge of a fast pace, physical demands and sheer grit to “get down there and nail the problem”. My residents today crave reassurance from me that they are progressing, something that I didn’t ever seek from my professors as I picked their brains for every ounce of knowledge that I could acquire.

When I completed my training, I too became part of a large practice group though I enjoyed a bit more autonomy because I enjoyed procedures and patients that my partners hated, perhaps my radical nature. Since I am willing to treat chronic wounds, hemodialysis patients, burned patients (most long-term), my colleagues have granted me a measure of being a free spirit which feeds my soul in medicine.

My primary care colleagues who crave connection with their patients are constantly being forced to limit patient contact. Couple limited patient contact with more time spent battling electronic patient record systems that do not meet needs, more regulations and less autonomy, it is no wonder that many have begun to look for other means of making a living outside of medicine. One of my friends just said that she is “tired” and “depressed” most of time. “I just have no joy in getting up and heading off to the office.”

Getting our souls back

How is it that we begin medical school with so much compassion and empathy only to end up dissatisfied and unhappy? Certainly the process of learning and acquiring the knowledge, application of that knowledge base and training can’t have removed that drive, compassion and empathy that got us through the undergraduate process (at high level) only to crash, so to speak, in the actual practice of our craft.

As I have moved though practice, I have become more dedicated to reaching and communicating with my patients. It is that patient interaction that enriches my sense of satisfaction with my work. My partners love that I will take on the more chronic patients that require more time and a more concerted effort. What I have found is that as I interact, especially with my patients that communicate less verbally, I am the one that is enriched.

Many times, it may be a sparkle in the eye or a touch on the hand that sparks a communication soul to soul. These small gestures may take more time but the results can be nothing short of amazing. When I speak of “caring” for patients, I strive to deliver that care. Rather than pushing patients to a periphery, I seek to draw them in closer. For me, this is the essence of why I entered medicine.

Many have questioned why a surgeon would be the one who wishes to connect on a deeper level with patients. After all, my practice is heavily skewed towards procedures but I maintain that my interaction on a deeper level with my patients is where I derive my satisfaction and my spirit in medicine. When the pressures of obtaining a corporate profit from patient care outweigh my ability to give the care to each of my patients, my days with that corporation are over.

A few months back, I was rounding with my team on the surgical floor. The chief resident and I were listening to an intern present the patient whose room we were about to enter. “The is a 75-year-old non-verbal male with dementia..”, he explained. He went on to state that the patients behavior had made evaluation of his severely infected diabetic foot ulcers very difficult. As we entered the patient’s room, I immediately grabbed a chair, pulled up close to the gentleman who was seated at bedside in the early morning.

I gently spoke a greeting softly to him; his eyes changed for a brief second; as I touched his hand gently (thankfully my hands were not their usual chill). I kept my right hand on his left hand as I explained why all of these people were in the room. As I took his right hand in my left hand, the chief resident picked up my “cue” and knelt down to look at the patients feet. I gently stroked both of the patients hands while chief removed the dressings and examined the wounds (in dire need of debridment). My eyes did not leave the eyes of this gentle soul as I spoke to him about his foot in soft tones, a great connection.

When we had completed the exam-yes it took a bit more time, I gently touched his face and said that we would speak to his daughter about the needed procedure. When I met the patient the next day in the holding area of the operating room, he reached out and gently touched the strand of pearls that are my signature. Yes, those small connections are why I do what I do and are immensely satisfying for me.

Final Thoughts

In yesterday’s Boston Globe, Bella English wrote about Massachusetts General Hospital’s Empathy and Relational Science Program. This program emphasizes training for physicians in empathy which “enhances relationships, increases job satisfaction and improves patient outcomes”. The importance of striving to develop relationships with our patients is of vital importance for our well-being as clinicians as well as for our patients. There is data now available that documents decreases in stress and decreases in malpractice claims. According to Dr. Helen Reiss, a psychiatrist who runs the MGH program, “Patients don’t sue doctors they like, with whom they have a meaningful relationship and whose intentions were good,” Good will and the building of meaningful relationships with patients by seeing the dignity and elegance in all of our patients regardless of our patients’ ability to communicate with us is a vital part of enhancing our enjoyment of medicine and why we are here in the first place.

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Yes, very well said! I Will share this post with my daughter who is just now going into her residency. It is unfortunate that many of the things that make up the practice of medicine today are exactly the things that are turning those that always wanted to be doctors and have empathy for their fellow man,
away from the practice
.

So so hard currently for family doctors. It’s a real struggle to keep up with the demand of patients, entitlement and the reality of paperwork. Sigh. I remember writing those same things on my application

Thank you for posting this. Hopefully the current conditions will not discourage people from going into medicine. It is really inspiring that you are still so dedicated and passionate about medicine even with these challenges facing doctors. All the best 🙂

To Malaika:
The current conditions tell me that it is up to me to change the current conditions. This is why I am writing more about some of the social/political aspects of medicine. The current system is not good for us as physicians and certainly not good for patients. Thank-you for reading.